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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 515108 0
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Richmond Acres LLC, C/o Gerald J. Smith Richmond, Town of 026- 1294 -43 -000
CST BM Elev: Insp. BM Elev: BM Description: Sectionfrown /Range /Map No:
�"(� • d p ►� V►. �' 28.30.18.1525
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
/oOD sue. p /m /v
Dosing Q Alt. B i171, - �0 1
Aeration Bldg. Sewer �f3��,
Holding St/Ht Inlet F^/ r � 95
TANK SETBACK INFORMATION St/Ht outlet SGy 1 /0
TANK TO P/L WELl BLDG. Vent to Air Intake ROAD Dt Inlet '
je 54 Septic Dt Bottom
Dosing Header /Man.
7
Aeration DisPipe t_
Holding Bot. System l � S
D.
Final Grade
PUMP /SIPHON INFORMATION ,
Manufacturer Demand St Cover V �f D
GPM
Model Number
TDH Lift Fric ss S m Head TDH Ft
Forcemain Length a. t. to Well
SOIL ABSORPTION SYSTE S
BED /TRENCH Width i Length / No. Of Trenches 1PITDIM�IVSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1�� s � Ov
SETBACK SYSTEM TO P/L 6L w WELL LAKE /STREAM LEACHING Manu /Tim 101�
INFORMATION CHAMBER 0
Tyr Of System: / S�,F / UNIT Model Number:
�S /,J
I : j
IBUTION SYSTEM
Head anifold Distribution { x Hole Size x Hole Spacing n Air jptakQ
Q / Pipe(s) �
Length 1l Dia � Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over L Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center , / 7 �� Bed/Trench Edges / Topsoil / O
pYesy� No d Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: _LL Q / / ✓Inspection #2:
Location: 1145 132nd Ave New Richmond, WI 54017 (SW 1/4 SE 1/4 28 T30 %1318W) Richmond Acres Lot 43 "� Parcel No: 28.30.18.1525
1.) Alt BM Description = �OIX%f - f ""tj1a
2.) Bldg sewer length = Aa
- amount of cover =� I �� t�21(
Plan re �ion R equired ? Yes No
Use other side for addition atio
Daft Insepc&ors ignatu C/J Cert. o.
SBD -6710 (R.3/97) W rct
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commerCemi.gov Safety and Buildings Division County
IN 201 W. Washington Ave., P. 62 -
' s cO n s' n Madison, Sanitary Perm N umber (to be fi m by Co.)
Department of Commerce Jl- % }
Sanitary Permit Applicatio# State Transaction Numb
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appro8(4te hfal r
unit is required prior to obtaining a sanitary permit. Note: Application forms fobs 1 are Project Address (if different than mailing address)
submitted to the Department of Commerce. Personal information you provit� used for secondary
purp oses in accordance with the Privacy Law, s. 15.04(1)Km), Stats.
I. Application Information - Please Print All Information
Prope er's Name Parcel #
ck,Y -r, o _cl Q ee_s'S kkC OZ z 4 Y; -o0
Property Owner's Mailing Address ;; Property Location
Y 3 3 �t: / cA/4 o tA S C IJ/— - Govt. Lot
City, State Zip Code Phone Number ,
/., S1� /., Section L
J VGi� , �t C h o, p A, w i S 1/0 17 T y N; R � E or W (circle one)
II. Type of Building (check all that apply) Lot #
N -1-or 2 Family Dwelling - Number of Bedrooms 3 T 3 Subdivision Name �p
Block# �L�,n✓+0�.� UC�GF.S ,
11 Public /Commercial - Describe Use
❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
ZTown of i C �sr✓t O !�-
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A ' New System ❑ Replacement System y p y ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain)
,..,,� List Previous Permit Imber and Date Issued
B. Permit Renewal LL''Permit Revision ❑Change of Plumber El Permit Transfer to New r -- -,
Before Expiration - -- " Owner I
IV. a of POWTS System/Component/Device: Check all that appl
on- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At-Grack Mound > 24 in. c�ss� le soil Q MouAn 4 in. of suitable 7 soil
�(
El Holding Tank
El Dispersal Component (explain
explain) / 71 > l ft� LJlretrea&' nt�D ice ex
V. Dis ersall'I'reatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required (sf) Dispersal Area Proposed (st) System Elevation
� 0 7 GY-5 (9 % - 7I:0 93. 9j
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units
New Tanks Existing anks w r d ti
g
a U cn y h w C7 a,
O or Holding Tank u-
Dosing Chamber
I. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POW TS s a the attached plans.
u tier's Name (Print Plumber's Signature /MPR umber Business Phone Number
4 C l'(E c 1+v >�� a.S Z ZZ-8 - 7Z-
PI tier's Address (Street, City, State, Zip Code)
Z4Sg Itro 5-1 Y.5 S3
VIII Coun /De artment Use Onl
Approved Disapproved Permit Fee Da Issued I mg Agent Signature `
❑ Owner Given Reason for Denial
IX. Conditions of Approval/Reasons for Disap roval
ip /(/t�G9L
V If- Z . o 5 ��� - 166 / C 71t `�'��'•�1��/ �1�� -� �.. h,
L �h GC f -rz� &
Attach to complete plans for the system and submit to the County only on paper not less than 812 x 11 inches in size
SBD -6398 R. 02/09 Valid thru 02/11
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Soil Absorption System Cross Section
5ched Final Grade
9 �.3 ft
Lea ching --► Chamber ft
�— System Elevation
3 ft Y _ft
Soil Absorption System Plan View
la 8
ft
3 ft
I
s ft Leaching Trench 1
Vent Or Observation Pipe Chambers
4" Dia.
Trench 2 Header
Leaching Chamber Specifications
Manufacturer And Model +,;ck- 1 4
EISA Rating Zo - 0 sq ft per chamber Soil Application Rate " gpd /sq ft
YJ gpd Design Flow + - -7 1 Soil Application Rate + 7- y EISA = 3 3
Chambers
2 rows of Z chambers each.
Page of
P/e s
��z07 7
Y - 71 s `7 k
commerceml.gov Safety and Buildings Division County _1
201 W. Washington Ave., P.O. Box 7162
i sc o n s i n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce 15 /vg
Sanitary Permit Application State Transaction Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the apri vemmental
p p
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for second S 3 Z ti v £
purp oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. /
I. Application Information - Please Print All Information
Property Owner's Name RECEIVE U Parcel #
C) e , ti o .Y., s lt."�tw j,L. OLG 1 29, 1 — vs-
Property Owner's �M g r aili Address JUL 2 9 2009 2s
Property Location /
I Y3 3 C� F GN Govt. Lot
c
City, State Zip Code 1 / 4, S£ ' %, Section
{�� ONING OFFICE ,mow 1,8
/ c E o ircle one!
�Ea✓ t h sw. 0l� d Lk-P , s � T 3 Q N; R �
Lk-
II. Type of Building (check all that apply) G k Lot #
P 1 or 2 Family Dwelling - Number of Bedrooms 3 3 Subdivision Name I
54,; 4e 1"6.3 Block � � G� rY✓1 d 1VCi Q��C.f S
❑ Public /Commercial - Describe Use
❑ City of
❑ State Owned - Describe Use CSM Number a ❑ Village of
1 ZSC L J 1 I �Q +41 g Town of Gh ter"+ v i-
III. Type of Permit: (Check only o9lb box on line A. Complete line B if applicable)
A ' ew System ❑ Replacement System g p y g y (explain)
❑ Treatment/Holdin Tank Re Onl Other Modification to Existin S
B. ❑Permit Renewal ❑Permit Revision ❑ List Previous Permit Number and Date Issued Change of Plumber ❑Permit Transfer to New
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that apply)
t
V Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank Other Dispersal Component (explain) ❑ Pretreatlment Device (explain)
V. Dis ersallTreatment Area Information: -) f (,C1?/t/
Design Flow (gpd) / Design Soil Application te(gpdsf) Dispersal Area Required Dispers Area Pro sed System Eleva 'on
9 /Zp 93 9.3 3 3 93 z 9.3.1,3
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units o eJ
New Tanks Existing Tanks n 2 S e A
£sl GA / e 4U h h V.Q a
eptic Holding Tank \/ / Qa0 / S C. w V
Dosing Chamber T /�
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS sho the attached plans.
ber's Name (Print) / � Plumber's Signature MP RS umber Business Phone Number
GCC k� / r— / � i
Pl ber's Address (Street, City, State, Zip Code)
2-1. l 5o -11h 7 k
VIII. Coun /De artment Use Onl
Approved TO Disapprove Permit F Date I ued xx q Issuin gent Si tur
Reason for 1 $ V `
IX. Conditions of Approval/Reasons for Disapproval dYSTEM 9WNE .
U �,_ � 0 ✓e- 7 / s MCA a 1. Septic lank, efflu6nt finer and
/ / i dispersal cell must all be services! maintained
VE �- as per management plan provided by plur OW.
Z - 0 5-,0
-- / Q 6 1 Pl N D I 1 G/ J 2 All setback mquirements must be rnaitftW
// •i as per appNcW* code / ordWwww
Attach to complete p lans for the syste and submit to the County only on paper not less than 81/2 x 11 inches in size
3 Q,1;IL l+�¢o � o�t[' P �d new Itia,..cow�.ctS w. S-1... �� r
SBD -6398 (R. 02/09) Valid thru 02/11
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Wisconsin Department of Commerce "✓'' "" EVALUATION REPORT Page _J of
Division of Safety and Buildings �s
in accordance with Comm 85, Wis. Adm. Code
County S-� � C a I
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal referenc po n Parcel I.D. 1 G
percent slope, scale or dimensions, north arrow, and loca on an Doad. Q l d.. < 7 ,3
Please print all informat n. 1." R ew at
Y P Y N P (A444 o K0�n
Personal information you provide may be used for seconds ur oses P a s 5. )). � V
Property Owner Property Locati S W
/` e r Q 1 C r •t ST. CRO �l�l� 1/4 S: 1/4 S a $ T30 N RJR E (or
Property Owner's Mailing Addre p Subd. Name or CSM#
/ q p e. NW Plat o F is m crc
City State Zip Coda Phone Number ❑ City ❑ Village ® Town Nearest Road
r d
F1K R��R �1N 3 ( 8 R►ic.hrn a 14�
($ New Construction Use: (15 Residential / Number of bedrooms 3 Code derived design flow rate S 0 _, GPD
❑ Replacement ❑ Public or commercial - Describe: _ —
Parent material —01v J- c-S L- % _ Flood Plain elevation if applicable — ___ It.
Genera► comments S Su,5 Se- S -+ 3 - T r-e r. e- ►" S t 5) F O r a 4` IT
and recommendations: �".
`—
T.� (g3,33�� T.1 (g3.o3') �Un 0 l2. ►'oLJN r " �:F+
5 +� f , -r.a (43.a3�� s> ' . T.-5 ( 92 .93')
T.3 (13.13') TIl. l 9 '2•83')
Boring # F1 Boring QQ
pit Ground surface elev. _90 • ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
lUY 3iA _ 5L a MP L r a W 0
11 -/ei -7. S YrZ 5i SL I �s tJ r
a y o_ i-Y, L L 7 1, to
-55 - 7, Y;S'�,. ` .� ) r Cc 5 1, d
tr �
bow
® Boring # Boring 5�' /
Pit Ground surface elev.. 17.3 ft. Depth to limiting factor �� in. Soll !cation Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD,NF
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
U - �0 �� 5L s b r4r at) -
- r !c 1. 0
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g
Effluent #1 = BOD > 30 5 220 mg/L Jna TSS 410 150 mg/L • Effluent #2 = BOD 5 30 mg/L and TSS < 30 mg/L
T Name (Please P Signature CST Number
A d a b lk �. Date Evaluation Conducted Telephone Number
' W:L _aa —off` - 7 rya 3588
50aIV
. t
Property Owner Gera ld6 Sm � Parcel 10 # Page_ of
F--31 Boring # ❑ Boring
Pit Ground surface elev. Depth t limiting ft in
9` �! ft. epo mng acor , Soil iication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
5 L 1 ri r c Li 1
D- r si --- --°- -� 5 I 6K M-Fr - -- 5
a Boring # ❑ Boring _— —
❑ Pit Ground surface elev. _ ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff #1 'Eff#2
F-1 Boring # ❑ Boring —
❑ Pit Ground surface elev. _ ft. Depth to limiting factor In.
Soil Application Rate
Horizon Depth Dominant Color Redox Desorption Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = SOD > 30 _< 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777.
SBD•8330 (R.6=)
Property Owner Gery It� Sm 4k Parcel ID # _ Page C =Z of
Boring # ❑ Boring q r
P Pit Ground surface elev. _`�+'! ft. Depth to limiting factor in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structbjre Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
" 1 _ S L I k y " G- LJ
>_..
l�
Boring # ❑Boring ow I
❑ pit Ground surface elev. ft. Depth to smiting factor in. Soil licafjon Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
F-1 Boring # E] ❑ Pit Boring
Ground surface elev. _ ft. Depth to limiting factor In.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and: employer. if you need assistance to access services or
need material in an alternate format, please contact the departmrtnt at 608 - 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (RAM)
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MIM MW APPHWANG AUTHORI
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SURWY MAP /'ENDING 18. T. 30 K. RAS W. Tmw � Ri„uwn
Soil Absorption System Cross Section
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ST. CROIY COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer 0 Ct"f
Mailing Address y3 3 ��- ,�,�,�j yuJL DA, A" f w �j,Gt„y,., ��c� �y 3�0�7
Property Address
(Verification required from Planning & Zomn Department for new construction.)
City /State Parcel Identification Number o Z L- r z q j - p u 0
LEGAL DESCRIPTION
SC 5 w
Property Location Sw 1 14 , 5--1 ' /4 , Sec. L T 30 N R /8 W, Town of
Subdivision Plat: - ;Cb,Y,-, je -cl i9el -r_v , Lot # V3
Certified Survey Map # , Volume , Page #
Warranty Deed # (before 2007)Volume Page #
Spec house yes Yno Lot lines identifiable Yyes ' no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and /or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
I /we certify that all statements on this form are true to the best of my /our knowledge. I /we am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms S
7 / o
9
SIGNATURE OF PPLICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
l
FILE INFORMATION r-%j 1 Uvvlvtn"5 MANUAL & MANAGEMENT PLAN Page of
,
Owner SYSTEM SPECIFICATIONS
Septic Tank Capacity
Permit i1 /,000 a l ❑ NA
Septic Tank Manufacturer � w 13 NA
DESIGN PARAMETERS Effluent Filter Manufacturer
Number of Bedrooms 6e-S f ❑ NA
.3 ❑ NA Effluent Filter Model &5`7 f='Q El NA
Number of Public Facility Units -EMA Fm 0 ank ank Capacity
Estimated flow (average) -�j
al a0 NA
al /day Manufacturer �l7 -R1A
Design flow (peak), (Estimated x 1.5)
7� al /day anufacturer ,ANA Soil Application Rate al /da /ft2 del Standard Influent /Effluent Quality Monthly average* ent Unit Fats, Oil &
Grease (FOG) 530 m /L g Gravel Filter E03 Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L 43N ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s)
Biochemical Oxygen Demand (BODS) ❑ NA
S30 mg /L n- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L 42 ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) x10 cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. NA Other: 13 NA
Other:
8 NA other: E3 NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every; ❑ month(s) (Maximum 3 ears) ❑ NA
- O] ear(s) y
Pump out contents of tank(s) When cEonceevery: ludge and scum equals one-third (Y) of tank volume 13 NA
Inspect dispersal cell(s) At least ry: ❑ month(s) (Maximum 3 years) ❑ NA
43 Clean effluent filter At least y; 0 a�lsj ❑ NA
Inspect pump, pump controls & alarm At least ) - OSonth(s) ❑ NA
c0 ❑ year(s)
Flush laterals and pressure test At least once every: 1 ❑ month( sl ❑ NA
- l3
Other: ❑ month(s)
At least once every: ❑ year(s) ❑ NA
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the cal regulatory authority within 10 days of completion of any service event.
d GMW (4/01)
Z 4 2- c9 72
of the tanKlsl removeo ny a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface. ,
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent, To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells, Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time,
• A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
• The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
• Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with t> rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS JNS7ALLER POWTS MAINTAINJER
Name c 14 a, vi K, ' r- 5 Name ct C. L �r.,,, K, IV,
Phone L Z L / Z-/ Phone Z
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name `, ella %"K
Phone Phone 3f(, - 14.0 (J
This document was drafted in compliance with chapter Co 3.22(2)(b)(Uld) &(f) as 8�(2) & (3), Wisconsin Administrative Code.
/�Ir°,GS 7- zL5�7�
(1 2851P 0 ?? 8r�14c3 ��
State Bar of Wisconsin Form 3 -2003 KATHLEEN H. WALSH
QUIT CLAIM DEED REGISTER OF DEEDS
ST. CROIX CO., WI
Document Number Document Name RECEIVED FOR RECORD
07/26/2005 10:00AM
QUIT CLAIM DEED
THIS DEED, made between Gerald J. Smith and Jeannine B. Smith, husband and EXERT # 10
wife REC FEE: 13.00
( "Grantor," whether one or more), TRANS FEE:
and Richmond Acres, LLC, a Wisconsin limited liability company COPY FEE:
( "Grantee," whether one or more). CC FEE:
PAGES: 2
Grantor quit claims to Grantee the following described real estate, together with the rents, Recording Area
profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin
( "Property ") (if more space is needed, please attach addendum): Name and Return Address
See attached Exhibit A Kristina Ogland
Attorney at Lw
P,O, Box 359
Hudson, WI 54016
026- 1082 -40- 000:026- 1083 -10 -000: 026 -1082-
70 -000: 026 - 1082 -40 -000
Parcel Identification Number (PIN)
This is not homestead property.
Dated'"
i
(SEAL) (SEAL)
erald J. SmAh Ifeannine B. Smith
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
authenticated on STATE OF w iss. , ' ;1 rA )
�1 ) ss.
�t - C 1lX COUNTY )
TITLE: MEMBER STATE BAR O ONS Personally came before me on
(If not, he above -named Gerald J. Smith and Jeannine B. Smith
authorized by Wis. Stat. § 6.� > usband and wife
o me known to be the person(s) who executed the foregoing
THIS INSTRUMENT DRAFTED B instrument and acknowledged the same.
` TE
Kristina Ogland, Estreen & Ogland "�IgItINIM� r`-
304 Locust Street, Hudson, WI 54016
Notary Public, State of
My Commission (is permanent) (expires: 9ra S'b5 )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
QUIT CLAIM DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 3-2003
* Type name below signatures. INFO -PROTM Legal Forms 800 - 655 -2021 www.infoproforms.com
U 2851 P 078
EXHIBIT A
Parcel l :
The East Half ofthe East Half ofthe Southwest Quarter (El /2/El/2/SWl /4) of Section Twenty Eight
(28), Township Thirty (30) North, Range Eighteen (18) West, Town ofRichmond, St. Croix County,
Wisconsin, EXCEPT Lot One (1) of Certified Survey Map filed April 24,1990, in Vol. 8 ofC.S.M.,
pg. 2199, as Doc. No. 457843, being part of the Southwest Quarter of the Southeast Quarter
(SW 1 /4/SE1 /4) and part of the Southeast Quarter of the Southwest Quarter (SEX /4/SW1/4), both in
Section Twenty Eight (28), Township Thirty (30) North, Range Eighteen (18) West.
Parce
The West Half of the Southeast Quarter (W1/2/SE1 /4) of Section Twenty Eight (28), Township
Thirty (30) North, Range Eigliteen (18) West. Town of Richmond, St. Croix County, Wisconsin,
EXCEPT the following described parcels:
1. Lot One (1) of Certified Survey Map filed April 24, 1990, in Vol. 8 of C.S.M., pg.
2199, as Doc. No. 457843, being part of the Southwest Quarter of the Southeast
Quarter (SW 1/4/SEI /4) and part of the Southeast Quarter of the Southwest Quarter
(SE1 /4/SW1/4), both in Section Twenty Eight (28), Township Thirty (30) North,
Range Eighteen (18) West;
2. Lot One (1) of Certified Survey Map filed August 13,1981, in Vol. 4 of C.S.M., pg.
1093, as Doc. No. 372738, being part of the Southwest Quarter of the Southeast
Quarter (SWl /4/SEI /4) of Section Twenty Eight (28); Township Thirty (30) North,
Mange Eighteen (18) West;
3. Commencing at the Southwest corner of Lot One (1) of Certified Survey Map filed
August 13, 1981, in Vol. 4 of C.S.M., pg. 1093, as Doc. No. 372738, for the point of
beginning; thence N89 °59'15" West 20.00 feet; thence NO*01'41" But 262.00 feet;
thence S89 0 59'15" East 224.00 feet; thence SO °01'41" West 15.00 feet; thence
N89 °59'15" West 209.00 feet; thence SO °01'41" West 242.00 feet to the point of
beginning;
4. Commencing at the Northeast corner of the Northwest Quarter of the Southeast
Quarter (NWX /4/SE1/4) of said Section ' 28; thence South 16 feet; thence
Northwesterly to a point 10 feet West of the point of beginning, thence East to the
point of beginning.
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